Request for Additional Information | 277 RFAI

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PDI or Claim ID

Health Care Claim Status Category Code Required

LOINC Code Required

LOINC Code Modifier Required

Contact Information

Claim Information All claim information is required.

Claim-Level Line-Level

Payer Name Enter a valid Name.

Payer ID Enter a valid Number.

Payer Claim Control Number Enter a valid Number.

Response Due Date mm/dd/yyyy Enter a valid Date.

Billing Provider Name Enter a valid Name.

Billing Provider NPI Enter a valid Number.

Billing Provider TIN Enter a valid Number.

Patient Last Name Enter a valid Name.

Patient First Name Enter a valid Name.

Patient Identifier Enter a valid Number.

Patient Control Number Enter a valid Number.

Information Receiver Enter a valid Name.

Bill Type Enter a valid Name.

Clearinghouse ID Enter a valid Number.

Medical Record Number Enter a valid Number.

Service From Date mm/dd/yyyy Enter a valid Date.

Service To Date mm/dd/yyyy Enter a valid Date.

Service Line Information

Service Line	Service From	Service To	Revenue Code	Procedure Code	Modifiers	Charge Amount

Claim {{ model.claimId }} Information

Payer Name	Payer ID	Payer Claim Control Number	Response Due Date
{{prepopulatedInfo.payerName?prepopulatedInfo.payerName:'---'}}	{{prepopulatedInfo.payerId?prepopulatedInfo.payerId:'---' }}	{{prepopulatedInfo.payerClaimControlNumber?prepopulatedInfo.payerClaimControlNumber:'---'}}	{{prepopulatedInfo.responseDate?prepopulatedInfo.responseDate:'---'}}
Billing Provider	Billing Provider NPI	Billing Provider TIN
{{prepopulatedInfo.providerInformation?prepopulatedInfo.providerInformation: '---'}}	{{ prepopulatedInfo.providerNpi?prepopulatedInfo.providerNpi: '---' }}	{{ prepopulatedInfo.providerTin?prepopulatedInfo.providerTin: '---' }}
Patient Last Name	Patient First Name	Patient Identifier	Patient Control Number
{{ prepopulatedInfo.patientLastname?prepopulatedInfo.patientLastname:'---' }}	{{ prepopulatedInfo.patientFirstName?prepopulatedInfo.patientFirstName:'---' }}	{{ prepopulatedInfo.patientIdentifier?prepopulatedInfo.patientIdentifier:'---' }}	{{ prepopulatedInfo.patientcontrolNumber?prepopulatedInfo.patientcontrolNumber:'---'}}
Information Receiver	Bill Type	Clearinghouse ID	Medical Record Number
{{ prepopulatedInfo.informationReceiver?prepopulatedInfo.informationReceiver:'---' }}	{{ prepopulatedInfo.billType?prepopulatedInfo.billType:'---'}}	{{ prepopulatedInfo.clearingHouseId?prepopulatedInfo.clearingHouseId:'---'}}	{{ prepopulatedInfo.medicalRecordNumber?prepopulatedInfo.medicalRecordNumber:'---' }}
Service From Date	Service To Date
{{ prepopulatedInfo.serviceFromDate }}	{{ prepopulatedInfo.serviceToDate }}

Service Line Information Select lines to include in RFAI.

	Service Line	Service From	Service To	Revenue Code	Procedure Code	Modifiers	Charge Amount
	{{line.serviceLineId}}	{{line.serviceFrom}}	{{line.serviceTo}}	{{line.revenueCode}}	{{line.procedurecode}}	{{line.modifiers}}	{{line.chargeAmount \| currency:'USD':true:'1.2-2'}}